Sunday, 14 March 2010

Confidence

Hi,

A very full week, but very little time to write about it, unfortunately. I got more 'on take' experience, spent some time with a very optimistic lady undergoing radiotherapy for a cancer on her face and spent a day with an F1, where I got to do LOTS. Did my first Arterial Blood Gas (ABG). A wonderful week, but I enjoyed it too much, and now have an essay deadline for Monday (tomorrow) so I will try and be concise and brief, so as to finish the essay tonight and get some sleep!

Ok, I had a great time when I was on take again this week. Spending much of the day on take, until about 8PM, it also gave me a good taste of what it is like to work as a doctor (not that I will get that privilege for another good few years!) Anyway, the set up is the same as last week and I was seeing patients who were being admitted from A&E, or who were referred to the hospital from their GP. Their names are written down as they come in from these respective locations on a list, and as medical students we get to clerk them from here. This can take a good hour a patient if done thoroughly, and is like being a 'real' doctor. You start off knowing very little about the patient, just one sentence which has been put down on this list 'confused with abdo pain' or the like, and you have to do a full history and examination from this. Presenting this to the doctor in charge, they then want your differential diagnoses (very important across medicine) and your initial management plan. Very exciting!

Anyway - when I was on take I clerked in several people, including an old lady who had come in after falling on the floor and being there for over 24 hours before being found. Being too weak to lift herself, all she could do was lie there and wait. The history taking was complicated as she had slight alzheimer's and was absolutely starving and really wanted something to eat. I made sure I got her one of those NHS snack packs (like a lunch box, for those who haven't seen them, with sandwiches, biscuits etc. inside) which she wolfed down faster than I thought possible, then promptly fell asleep. On trying to wake her up (slightly afraid something terrible had happened due to the speed at which it happened) I got told to go away as she was sleepy. I wasn't really sure what to do here, she needed to be seen so treatment plans could be made, but if she wasn't going to talk to me there wasn't much I could do. As it was, I came back in 15 minutes and she was awake again (odd lady) and rather sheepishly apologised for being blunt and offered to help me finish off my history. Anyway, to cut a long story short, it seemed she had got a UTI which had caused her to fall (common causes of all evil in old people) which we could easily treat with an antibiotic such as co-amoxiclav. For the rest of the day, whenever I went past her bed I got a lovely smile and wink from her over some plate of food or other. While she had fallen and stayed on the floor for a day, perhaps she hadn't eaten for a week before that! It was either that or she was the 'Big Bad Wolf' who had snuck in in disguise to get some free food!

Another patient I saw on take was a kind Gent who was suffering from photophobia and headache. Typical meningitis alarm bells here. As you may be aware, untreated bacterial meningitis nearly always kills the patient. This is always something to be on the look out for to treat fast! The crucial diagnostic test for meningitis is a lumber puncture, where a needle is pushed into the spinal canal to take a sample of the CSF (the juice the brain is suspended in). The doctor asked me if I would be interested in doing this procedure. I know the drill, push the needle in between L3/L4 (low enough to avoid hitting the spinal chord, which has split into the stringy "cauda equina" by then) until you get some flashback and then take some samples. I was NOT happy to do this. I am usually really up for trying any new procedure I can get my hands on, and as long as you are honest, smiley and seem confident towards the patient they don't seem to mind. But a procedure involving sticking a needle right next to their CNS, with a risk of paralysis is out of my depth. A good thing too, seeing as when I saw it done it took the (highly skilled) registrar a good 15 minutes of 'poking around' (I believe that is the technical term) after putting the needle in before they got the flashback. I contented myself with taking his blood instead, after the procedure when he was complaining of a [more] shattering headache (common side effect, changing the pressure around the brain). He told me his veins tended to flummox medical professionals seeming to disappear and refuse to yield more than a few mm of blood when found. But he had a cannula in, so I reasoned they couldn't be that bad. I managed to get a vein nicely the first time, filling the necessary bottles, which felt good - but then again perhaps the fear from the lumber puncture had dilated his vessels after he had come through A&E and they had had their go. Still made me feel good though, I can still become that doctor figure I want to!
[If anyone was curious, he didn't have meningitis]

Despite all of this, my last day this week was still the best day for me. I ended up spending almost the entire day with an F1 doctor (first year after graduation) doing all of her tasks with her. This was more through choice than anything else, as the timetable is somewhat vague. We developed a quick 'you scratch my back' type relationship over the course of the day. I did a lot of her menial work, like filling out MMSE forms (which any monkey can do, it just involves asking questions clearly and ticking boxes) and filling out reams of figures on slips of paper to plot how patients blood results were changing from yesterday. That latter one seemed pointless, as the computer systems have a mode which can do this, but who am I to question why. Anyway, in return for the running around with X-ray forms and other fun things I got to do I got bought a cup of coffee and, by far best of all, got to do an ABG. I was also asked if I would like to catheterise a male patient but I declined as I had only ever practised on a plastic model and had never seen it done before. I got to do plenty of bloods and other such wonderful things, but lets focus on the highlight of my week.

An ABG is where a needle is stuck into the wrist at a steep angle to go and pierce the radial artery (the one you can feel with your fingers at your wrist). This is needed to see the levels of oxygen, CO2 and the pH of the blood. You need to get this information from an artery, as you want to know how much oxygen is getting to the tissues, not coming away from it. I have to be honest here, I don't think I have ever seen an ABG carried out in real life, but I have read about them (Wikipedia) and heard about them plenty. I suppose I may have seen one carried out on a programme like scrubs, if that counts. Anyway, when I was asked if I wanted to do one, I wasn't going to say no. They don't seem too hard, just feel for the artery with two fingers and stick the needle between them. After all - I seem to have a knack for finding veins, and you can FEEL arteries! I went and got the necessary hardware as the F1 asked me if I know about these.

"Yes, I have a pretty good idea of what it involves"
There we go. Not a lie at all, and said with a confident smile. Again, you can get so far with confidence.
"Sure, that's fine then, talk me through what you do as you do it then please!"
That's fine with me. I don't want to be left alone to do this at all! Unfortunately, as I come up to see the patient I suddenly feel really bad. Its one of the several alcoholics we have on the ward (being gastro there is always alcoholic liver disease around) and he has been very out of it for the last couple of days. I am more than happy with explaining myself to a nice patient, trying to win them over and then doing the ABG, but doing it for the first time on someone who is barely concious seems somewhat wrong to me. Yes, he is unlikely to care too much, but what about informed consent? Too late now, I can't really pull out. Better carry it out well!
I prep the area, unsure as to what help these alcohol wipes really have. I am sure I read somewhere they increase the chance in infection by breaking skin layers. Stop. Where did all of this doubt come from!? Before I saw this patient I was calmly confident - now I have noticed it is not someone who would care if I messed up why does it matter more?

"Would you mind if I took some blood from the artery in your wrist, sir? It might be a bit painful I am afraid"
Patient flops his hand forward and upside down, grunts in agreement but doesn't open his eyes. He isn't the sort you could have a conversation with, brain encephalopathic from chronic alcohol use. That seems like as much consent as I am going to get. I start feeling for the pulse. Not as strong as most people's I am sure - but perhaps that means the artery is bigger, and as such has less force on the walls? I don't know, I just want to stay calm and confident. That's the trick.

I talk the F1 what I am doing, angling at about 45 degrees and angling the bevel to catch the flood flow as soon as I hit the artery. The idea with this technique is that once you hit the artery the blood flow has enough force from being in the artery to fill up the needle, pushing the plunger out.
There is nothing else for me to wait for now - hesitation loses that confident air you need to keep. I push the needle in between my two gloved fingers. Not even a twitch from the patient, still sitting there with his eyes closed. I can feel the pulse on both, so the artery is definitely between them as well. But my fingers are big, and gloved, the artery small and hidden below all that flesh, what if I am a few mm to one side? I might miss it, or clip it and damage the wall, leading to lots of bleeding from the wrist. I don't want that! I am sure it is here somewhere, but it seems deeper that I might have thought... Keep the confidence!

Finally (so that's a little under a second in real time) I see a trickle of blood appear in the plastic part of the needle that attaches to the metal needle. Flashback! This is quickly followed by a nice squirt or two of blood squeezing into the syringe and filling it up. I pull it out, making sure to cover immediately with gauze and keep pressure on for a good minute to stop bleeding. Still no reaction from the patient. Where is the applause! Finished. Nice. First time. Relief.

I walk the sample over to the nearest analyser machine. No need to send it off to the lab to be analysed, these machines do it on the spot! The nearest one is over in ITU. I come back with the slip of printed paper. respiratory alkalosis I tell the F1, and walk them through how I came to this conclusion. More learning.

Well, that was exciting for me, though I did feel like am imposter through much of that. I think it must have been mainly due to the fact that the patient was not with it at all, just sitting there glazed, that made me feel bad for sticking a needle into him. I felt like the guy from the movie "Paper Mask" I had been recommended to watch by a member of hospital staff. It all worked out fine for me in the end, but boy am I glad I didn't accept that offer to practice a lumber puncture earlier! I suppose we all have to learn by trying something for the first time, and after that experience I am still up for giving these new things a go (but not all of them. I will steer clear of neurosurgery for a good few weeks, don't worry!)

The F1 has offered to let me practice catheterisation next week if I am around and there is the option for it to be done. Sounds good to me - just keep confident, right! If I can keep this symbiotic relationship with this F1 I can get to do loads of stuff. But we do have these 'log books' we have to collect proof we have done 'useful' things in, such as consultant ward rounds. The funny thing is, on some of the days this week, which have been unremarkable, I have collected around 5 signatures. This day I collected none. What can you do.

Anyway - this turned out FAR too long, and I am not going to read through it all again - so apologies for any parts which are poorly written / grammatically incorrect. I now need to get onto this essay so I get some sleep before my 8AM ward round tomorrow. Or is it 7.30?